Dr. Ifath Bashiruddin Dr. Rashid DalalTammi Jones, NP
Ph: 618-239-9500Fax: 618-239-9555
Patient Registration
Patient Name:
Last First M.I
Address:
Street City State Zip Code
Home Phone: Cell Phone:
Work Phone: Email Address:
SSN: Date of Birth: / / Sex: M F
Martial Status: S M O Spouse’s Name:
Primary Doctor: Referred By:
Emergency Contact:
Name: Relationship: Phone#:
Person Responsible for Bill:
Address if different from patient:
Insurance Information: Please have your insurance card available to copy for our records.
Primary Ins:
NameAddress City State Zip Code
Identification Number (SSN or Plan#)
Owner of Policy (Name) Date of Birth / /
Secondary Ins:
NameAddress City State Zip Code
Identification Number (SSN or Plan#)
Owner of Policy (Name) Date of Birth / /
Employer Information:
Patient’s Employer:
Spouse’s Employer:
Please Sign and Date
Signature Patient, Parent, or Legal Guardian Date
Contact Preferences
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
Please check the boxes next to each method of communication you would like us to use:
Home
? OK to leave message with detailed information
? Leave message with call-back number only
? OK to mail
Work
? OK to leave message with detailed information
? Leave message with call-back number only
? OK to mail
? OK to fax
Cell phone
? OK to leave message with detailed information
? Leave message with call-back number only
Other:
The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. Please see the accompanying Notice of Privacy Practices for more information on our policies. Please list any individuals among your friends, family, or caretakers with whom we are authorized to discuss your protected health information. You should write your spouse’s name here if he/she is authorized. This is optional; if you do not wish us to discuss your PHI with anyone but yourself and your healthcare providers please leave this blank:
Name Phone Number Relationship
By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices.
______
Signature of Patient or Personal Representative Today’s Date
Authorization
I hereby authorize payment directly to the Physician of the Surgical and/or Medical Benefits, if any, otherwisepayable to me for his/her services as described, realizing I am responsible to pay non-covered services. Ihereby authorize the Physician to release any information acquired in the course of my treatment necessary toprocess insurance claims.
I authorize any holder of medical or other information about me to release this information to my insurancecompany, its intermediaries or carriers, to my attorney or to another physician’s office. I also permit a copy ofthis authorization to be used in place of the original. This agreement will remain in effect until revoked by me inwriting.
SIGNATURE:______DATE:______
I,______, hereby request that you release to
Midwest Nephrology and Hypertension Associates/Infectious Disease Consultants Group
4550 Memorial Drive, Ste. 360
MedicalOfficeBuilding One
Belleville, IL62226
Phone (618) 239-9500
Fax (618) 239-9555
A report of my diagnosis, treatment, prognosis, and recommendations, as well as other data pertinent to your treatment of me from ______to______.
______
(Date of Request) (Patients Signature)
Authorization Form
Release of Confidential Health Information
I, , hereby authorize to release to:
(Name of Patient of Authorized Agent) (Name of Physician)
(Name of Health Care Facility, Physician, Agency, etc.)
(Street Address, City, State, and Zip Code)
the following information contained in the patient record of
(Patient’s Name)
born / / , residing at :
(Month, Day, Year) (Street Address, City, State, and Zip Code)
The entire medical record, excluding mental health treatment, alcoholism treatment, drug abuse treatment, and HIV/acquired immune deficiency syndrome (AIDS) records
To be disclosed, the following items must specifically be checked:
Mental Health Treatment Records
Alcoholism Treatment Records
Drug Abuse Treatment Records
HIV/Acquired Immune Deficiency Syndrome (AIDS) records
Laboratory Reports
X-Ray Reports
Operative Notes
Genetic Testing
Other:
The above information for the following period of time shall be released:
From: to .
(Date) (Date)
The purpose(s) of the authorization is (are)
I understand that I have the right to inspect and copy the information I have authorized to be disclosed by this authorization. In the event I refuse to authorize the release of the above described information, I understand that it will not be disclosed, except as provided by law.
I understand that the practice may not condition treatment on whether I sign this authorization, except when the provision of health care is solely for the purpose of creating protected health information for disclosed to a third party.
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by law.
I understand that this authorization is valid until it expires, unless revoked before that.
I understand that I may revoke this authorization at any time by giving written notice to the physician of my desire to do so. I also understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or disclose my health information. Written revocation must be sent to the physician’s office.
Signed: Date:
If you are not the patient, please specify your relationship to the patient:
(11/09)
Privacy Practice Notice
Patient Copy
Notice available upon request beginning on the revision’s effective date. The revised notice is posted in the practice’s reception area and made available to all patients, including those who have received a previous Notice. Upon receipt of a revised Notice, a patient is asked to acknowledge receipt of the Notice.
Complaints: The practice allows all patients and their agents to file complaints with the practice and with the Secretary of the Federal Department of Health and Human Services (DHHS). A patient or his or her agent may file a complaint with the practice whenever he or she believes that the practice has violated their rights.
Complaints to the practice must be in writing, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to the attention of the practice’s privacy office at the practice address. The practice investigates each complaint and may, at its discretion, reply to the patient of the patient’s agent.
The practice does not take any adverse action against any patient who files a complaint (either directly or through an agent) against the practice.
Contact Person: The practice has a privacy officer that serves as the contact person for all issues related to the Privacy Rule. If you have any questions about this Notice, pleas contact our privacy officer at (618)239-9500 or by mailing it to Midwest NHA & Infectious Disease Consultants Attention: Privacy Officer - 4550 Memorial Drive – Medical Building A – Suite 360, Belleville, Illinois 62226.
USES AND DISCLOSURES
OF PROTECTED HEALTH INFORMATION
The practice reasonably ensures that the protected health information (PHI) it requests, uses, and discloses for any purpose is the minimum amount of PHI necessary for that purpose.
The practice treats all qualified individuals as personal representatives of patients. The practice generally allows individuals to act as personal representatives of patients. The two general exceptions to allowing individuals to act as personal representatives relate to the unemancipated minors and abuse, neglect, or endangerment situations.
The practice makes reasonable efforts to ensure that protected health information is only used by and disclosed to individuals that have a right to the protected health information. Toward that end, that the practice makes reasonable efforts to verify the identity of those using or receiving protected health information.
Uses and Disclosures – Treatment, Payment, and Health Care Operations
The practice uses and discloses protected health information for payment, treatment, and health care operations. Treatment includes those activities related to providing services to the patient, including releasing information to other health care providers involved in the patient’s care. Payment relates to all activities associated with getting reimbursed for services provided.
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
*You may refuse to sign this acknowledgement.*
I, ______, have received a copy of this
office’s Notice of Privacy Practices.
______
Please Print Name
______
Signature
______
Date
______
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
Acknowledgement could not be obtained because:
Individual refused to sign.
Communications barriers prohibited obtaining the acknowledgement.
An emergency situation prevented us from obtaining acknowledgement
Other (Please specify).
______
______
______
______
Office SignatureDate